An Evening with Bausch + Lomb - Washington DC - June 22, 2017 NPR.0172.USA.17

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* 1. First Name

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* 2. Last Name

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* 3. Middle Initial

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* 4. eMail Address

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* 5. Institution / Practice Name

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* 6. Office Street Address

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* 7. Office City

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* 8. Office State

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* 9. Office Zip Code

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* 10. Specialty / Office Role

Ophthalmologist

Optometrist

Office Staff

Medical Assistant

Ophthalmic Technician / Other Technician

Fellow or Resident

Other (please specify)

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* 11. License Number (Please indicate NA if you are not a licensed doctor)

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* 12. State of License (Please indicate NA if you are not a licensed doctor)

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* 13. NPI Number (US attendees only, International attendees please indicate NA)

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* 14. I confirm I have read, acknowledge, and will comply with the following AdvaMed and PhRMA requirements as related to this event:

Attendance is limited to eyecare professionals. Accordingly, we appreciate your support in not bringing a spouse or guest to this program. Healthcare Professionals licensed in Minnesota and Vermont may not attend this event due to their respective state laws and regulations that restrict the provision of meals to healthcare professionals. The value of refreshments and meals will be reported in compliance with the Physician Payments Sunshine Act and any applicable state laws.

I confirm

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* 15. I confirm I have read and agree with the terms of the Bausch + Lomb Privacy Policy.

I confirm